Page 1 of 197
FUNDAMENTALS EVOLVE HESI EXAM COMPLETE
NEWEST 500 QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE THIS YEAR
QUESTION: Ten minutes after signing an operative permit for a fractured hip, an older client
states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the
nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client's family to co-sign the operative permit. - ANSWER-Answer: B
This statement may indicate that the client is confused. Informed consent must be provided by
a mentally competent individual, so the nurse should further assess the client's neurologic
status (B) to be sure that the client understands and can legally provide consent for surgery. (A)
does not provide sufficient follow-up. If the nurse determines that the client is confused, the
surgeon must be notified (C) and permission obtained from the next of kin (D).
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QUESTION: The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which intervention should be included in this
instruction?
A. Perform range-of-motion exercises to prevent contractures.
B. Decrease the client's fluid intake to prevent diarrhea.
C. Massage the client's legs to reduce embolism occurrence.
D. Turn the client from side to back every shift. - ANSWER-Answer: A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints.
(B, C, and D) are all potentially harmful practices that place the immobile client at risk of
complications.
QUESTION: The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client
starts to fall. Which is the priority action for the nurse to take?
A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
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D. Gently lower the client to the floor. - ANSWER-Answer: D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the
client and the nurse. Lowering the client to the floor should be done when the client cannot
support his own weight. The client should be placed in a bed or chair only when sufficient help
is available to prevent injury. (A) is important but should be done after the client is in a safe
position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause
chaos on the unit and might alarm the other clients.
QUESTION: A female nurse is assigned to care for a close friend, who says, "I am worried that
friends will find out about my diagnosis." The nurse tells her friend that legally she must protect
a client's confidentiality. Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice - ANSWER-Answer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client
confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
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standards for nursing care but does not include legal guidelines. (C and D) describe expectations
for nursing practice but do not address legal implications.
QUESTION: The nurse is teaching a client how to perform progressive muscle relaxation
techniques to relieve insomnia. A week later the client reports that he is still unable to sleep,
despite following the same routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is achieved.
D. Ask the client to describe the routine that the client is currently following. - ANSWER-
Answer: D
The nurse should first evaluate whether the client has been adhering to the original instructions
(D). A verbal report of the client's routine will provide more specific information than the
client's written diary (B). The nurse can then determine which changes need to be made (A).
The routine practiced by the client is clearly unsuccessful, so encouragement alone is
insufficient (C).
4
FUNDAMENTALS EVOLVE HESI EXAM COMPLETE
NEWEST 500 QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE THIS YEAR
QUESTION: Ten minutes after signing an operative permit for a fractured hip, an older client
states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the
nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client's family to co-sign the operative permit. - ANSWER-Answer: B
This statement may indicate that the client is confused. Informed consent must be provided by
a mentally competent individual, so the nurse should further assess the client's neurologic
status (B) to be sure that the client understands and can legally provide consent for surgery. (A)
does not provide sufficient follow-up. If the nurse determines that the client is confused, the
surgeon must be notified (C) and permission obtained from the next of kin (D).
1
, Page 2 of 197
QUESTION: The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which intervention should be included in this
instruction?
A. Perform range-of-motion exercises to prevent contractures.
B. Decrease the client's fluid intake to prevent diarrhea.
C. Massage the client's legs to reduce embolism occurrence.
D. Turn the client from side to back every shift. - ANSWER-Answer: A
Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints.
(B, C, and D) are all potentially harmful practices that place the immobile client at risk of
complications.
QUESTION: The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client
starts to fall. Which is the priority action for the nurse to take?
A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
2
, Page 3 of 197
D. Gently lower the client to the floor. - ANSWER-Answer: D
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the
client and the nurse. Lowering the client to the floor should be done when the client cannot
support his own weight. The client should be placed in a bed or chair only when sufficient help
is available to prevent injury. (A) is important but should be done after the client is in a safe
position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause
chaos on the unit and might alarm the other clients.
QUESTION: A female nurse is assigned to care for a close friend, who says, "I am worried that
friends will find out about my diagnosis." The nurse tells her friend that legally she must protect
a client's confidentiality. Which resource describes the nurse's legal responsibilities?
A. Code of Ethics for Nurses
B. State Nurse Practice Act
C. Patient's Bill of Rights
D. ANA Standards of Practice - ANSWER-Answer: B
The State Nurse Practice Act (B) contains legal requirements for the protection of client
confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical
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, Page 4 of 197
standards for nursing care but does not include legal guidelines. (C and D) describe expectations
for nursing practice but do not address legal implications.
QUESTION: The nurse is teaching a client how to perform progressive muscle relaxation
techniques to relieve insomnia. A week later the client reports that he is still unable to sleep,
despite following the same routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is achieved.
D. Ask the client to describe the routine that the client is currently following. - ANSWER-
Answer: D
The nurse should first evaluate whether the client has been adhering to the original instructions
(D). A verbal report of the client's routine will provide more specific information than the
client's written diary (B). The nurse can then determine which changes need to be made (A).
The routine practiced by the client is clearly unsuccessful, so encouragement alone is
insufficient (C).
4
